Patterns of Drinking/Associated Lifestyle Factors

Critique 281 – Why do only some cohort studies find health benefits from low-volume alcohol use? A systematic review and meta-analysis of study characteristics that may bias mortality risk estimates – August 2024

Reference: Why do only some cohort studies find health benefits from low-volume alcohol use? A systematic review and meta-analysis of study characteristics that may bias mortality risk estimates. Stockwell T; Zhao J; Clay J; Levesque C; Sanger N; Sherk A; Naimi T. Journal of Studies on Alcohol and Drugs 2024 85(4): 441–452. doi.org/10.15288/jsad.23-00283

The recent study by Stockwell et al. (2024) claims that there is no safe level of alcohol consumption. It has been consistently shown in countless other studies, however, that moderate alcohol consumption is part of a healthy diet and lifestyle. The authors base their claim on a highly selective number of incorrectly referenced studies which misinterpret the original data and misrepresent the original conclusions

For the detailed critique of this paper by the International Scientific Forum on Alcohol Research, please click here.

Critique 283 – Alcohol consumption patterns and mortality among older adults with health-related or socioeconomic risk factors – November 2024

Reference: Ortolá, R.; Sotos-Prieto, M.; García-Esquinas, E.; Galán, I.; Rodríguez-Artalejo, F. Alcohol consumption patterns and mortality among older adults with health-related or socioeconomic risk factors. JAMA Network Open 2024 7(8): e2424495. doi:10.1001/jamanetworkopen.2024.24495

A study by Ortolá and co-authors in JAMA Network Open concluded that even low risk drinking was associtated with higher mortality among older adults with health-related or socioeconomic risk factors. However, the study did not use the appropriate control group in their comparisons. Also, the authors did not evaluate drinking pattern and eating habits. The Forum concludes that these limitations well explain why this single study contrasts the vast number of previous studies showing that light to moderate alcohol consumption is associated with reduced mortality.

For the detailed critique of this paper by the International Scientific Forum on Alcohol Research, please click here.

Critique 271 – Moderate alcohol consumption, types of beverages and drinking pattern with cardiometabolic biomarkers in three cohorts of US men and women

Reference: Li X; Hur J; Cao Y; Song M; Smith-Warner SA; Liang L; Mukamal KJ; Rimm EB; Giovannucci EL. Moderate alcohol consumption, types of beverages and drinking pattern with cardiometabolic biomarkers in three cohorts of US men and women. European Journal of Epidemiology (2023) https://doi.org/10.1007/s10654-023-01053-w

Cardiovascular diseases (CVDs) remain the leading cause of death globally, and leading risk factors for CHD and stroke include high blood pressure, high low-density lipoprotein (LDL) cholesterol, diabetes, smoking and second-hand smoke exposure, obesity, unhealthy diet, and physical inactivity.

Various randomized controlled trials have previously identified biomarkers that change with moderate alcohol consumption and which may explain its beneficial effects on CVDs. These biomarkers include HDL cholesterol, glycaemic control as HbA1c and adiponectin. Other relevant biomarkers changing with moderate alcohol consumption are fibrinogen, fibrinolysis, platelet aggregation, other lipoproteins, such as LDL cholesterol, HDL functionality, oxidative markers and triglycerides. This large epidemiological study provides further support for these beneficial effects but also highlights the beneficial effects on and inflammatory markers. The study also supports the importance of a regular and moderate pattern of alcohol consumption, not abstinence nor binge or heavy drinking, to maintain cardioprotection.

For the detailed critique of this paper by the International Scientific Forum on Alcohol Research, please click here.

Critique 263 – Alcohol Drinking Patterns and Risk of Developing Acute and Chronic Pancreatitis – 17/04/2023

Reference: Reference: Alcohol Drinking Patterns and Risk of Developing Acute and Chronic Pancreatitis
Authors. Becker U, Timmermann A, Ekholm O, Grønbæk M, Drewes AM, Novovic S, Nøjgaard C, Olesen SS, Tolstrup JS. 2023. Alcohol and Alcoholism Mar 1;agad012. doi: 10.1093/alcalc/agad012. Online ahead of print, 10pp.

Alcohol consumption has often been found to be a risk factor for acute pancreatitis (AP) and a number of biologic mechanisms for such an association have been suggested. Overall, however, the risk is rather low, as only 1-3% of heavy drinkers develop AP after 10-20 years of follow up.

This is the second study of the Danish National Health Surveys group investigating the association between drinking pattern and pancreatitis. A prospective cohort study based on data from 316,751 men and women participating in the Danish National Health Surveys 2010 and 2013, it specifically assessed the effects of type of alcohol as well as drinking pattern on risk of acute and chronic pancreatitis.

A J-shaped association between the consumption of alcohol and development of pancreatitis was observed particularly for beer and spirits where drinking frequency such as daily, frequent binge drinking and problematic alcohol use were associated with increased development of pancreatitis. The study is important because of its large number of subjects, apparently good ascertainment of disease, appropriate and well-described methodology, and the fact that data on the type of beverage were available. Further, it was carried out using data from subjects in a single country, thus is less likely to be confounded by mixing data from very divergent cultures.

Placed in perspective, however, both acute and chronic pancreatitis risk was shown to increase at higher levels of alcohol consumption, at leveles well above the definitions for moderate alcohol consumption. Furthermore, beverage type does not seem to be an important modulator of this risk, whereas problematic alcohol use was, even for the alcohol consumption adjusted hazard ratios.

Forum Member Professor R Curtis Ellison suggested that “while this paper on the relation of alcohol to pancreatitis mainly supports previous research on the topic, it is important due to its large number of subjects, apparently good ascertainment of disease, appropriate and well-described methodology, and the fact that data on the type of beverage were available. Further, it was carried out using data from subjects in a single country, thus is less likely to be confounded by mixing data from very divergent cultures… The key findings of this well-done study are that heavy drinking is associated with increases in risk of pancreatitis, whereas drinking within recommended guidelines for any beverage appears to not increase the risk.”

Concluding comments

Altogether, an interesting study that shows that acute and chronic Pancreatitis increases at higher levels of alcohol consumption, at least well above the definitions for moderate alcohol consumption. Beverage type does not seem to be an important modulator of this risk, whereas problematic alcohol use was, even for the alcohol consumption adjusted hazard ratios.

For the detailed critique of this paper by the International Scientific Forum on Alcohol Research, please click here

Critique 263 – Alcohol Drinking Patterns and Risk of Developing Acute and Chronic Pancreatitis – 17/04/2023

Reference: Alcohol Drinking Patterns and Risk of Developing Acute and Chronic Pancreatitis
Authors. Becker U, Timmermann A, Ekholm O, Grønbæk M, Drewes AM, Novovic S, Nøjgaard C, Olesen SS, Tolstrup JS. 2023. Alcohol and Alcoholism Mar 1;agad012. doi: 10.1093/alcalc/agad012. Online ahead of print, 10pp.

Alcohol consumption has often been found to be a risk factor for acute pancreatitis (AP) and a number of biologic mechanisms for such an association have been suggested. Overall, however, the risk is rather low, as only 1-3% of heavy drinkers develop AP after 10-20 years of follow up.

This is the second study of the Danish National Health Surveys group investigating the association between drinking pattern and pancreatitis. A prospective cohort study based on data from 316,751 men and women participating in the Danish National Health Surveys 2010 and 2013, it specifically assessed the effects of type of alcohol as well as drinking pattern on risk of acute and chronic pancreatitis.

A J-shaped association between the consumption of alcohol and development of pancreatitis was observed particularly for beer and spirits where drinking frequency such as daily, frequent binge drinking and problematic alcohol use were associated with increased development of pancreatitis. The study is important because of its large number of subjects, apparently good ascertainment of disease, appropriate and well-described methodology, and the fact that data on the type of beverage were available. Further, it was carried out using data from subjects in a single country, thus is less likely to be confounded by mixing data from very divergent cultures.

Placed in perspective, however, both acute and chronic pancreatitis risk was shown to increase at higher levels of alcohol consumption, at leveles well above the definitions for moderate alcohol consumption. Furthermore, beverage type does not seem to be an important modulator of this risk, whereas problematic alcohol use was, even for the alcohol consumption adjusted hazard ratios.

Forum Member Professor R Curtis Ellison suggested that “while this paper on the relation of alcohol to pancreatitis mainly supports previous research on the topic, it is important due to its large number of subjects, apparently good ascertainment of disease, appropriate and well-described methodology, and the fact that data on the type of beverage were available. Further, it was carried out using data from subjects in a single country, thus is less likely to be confounded by mixing data from very divergent cultures… The key findings of this well-done study are that heavy drinking is associated with increases in risk of pancreatitis, whereas drinking within recommended guidelines for any beverage appears to not increase the risk.”

Concluding comments

Altogether, an interesting study that shows that acute and chronic Pancreatitis increases at higher levels of alcohol consumption, at least well above the definitions for moderate alcohol consumption. Beverage type does not seem to be an important modulator of this risk, whereas problematic alcohol use was, even for the alcohol consumption adjusted hazard ratios.

For the detailed critique of this paper by the International Scientific Forum on Alcohol Research, please click here

Critique 250 – Importance of a favorable pattern of drinking (regularly, and with food) on risk of mortality –  28 July 2021

Reference:  Ma H, Li X, Zhou T, Sun D, Shai I, Heianza Y, Rimm EB, Manson JE, Qi L.  Alcohol Consumption Levels as Compared With Drinking Habits in Predicting All-Cause Mortality and Cause-Specific Mortality in Current Drinkers.  Mayo Clin Proc 2021;96:1758-1769.

This is an analysis based on a very large data base of alcohol consumers (subjects reporting > 0 g of alcohol/week) from the UK Biobank (analyses based on 316,627 subjects with a median follow up of 8.9 years).  The authors constructed categories of Drinking Habit Scores (DHS) for subjects; a “favorable” DHS was used for those subjects reporting a drinking frequency of 3 or more days/week and consuming alcohol with meals.  The investigators then related the DHS categories to subsequent all-cause and cause-specific mortality, with adjustments for essentially all of the common known confounders/modifiers of alcohol effect.

Overall, Forum reviewers agreed with the main outcomes of the study, which indicate that subjects with a favorable DHS (in comparison with other drinkers) had significantly lower all-cause mortality (HR=0.82), CVD mortality (HR=0.84); cancer mortality (HR=0.82), and death from other causes (HR=0.77).  In relation to the number of drinks consumed, the authors report that for all-cause, CVD, and other cause mortality, subjects with a favorable DHS showed a U-shaped or L-shaped curve (in that even for the heaviest drinkers, the mortality risk remained the same or lower than that of abstainers).  Only for cancer mortality was there an increase in risk for subjects in the highest category of alcohol intake, leading to a J-shaped curve.

While the authors did not report specifically on the types of beverage being consumed in their favorable drinking pattern, it is the typical pattern generally found in southern Europe, and typically it is wine with meals.  In these societies, wine is considered part of the meal, and is not consumed as “shots” that are usually being taken primarily as a way of getting drunk.  As described in this paper, it is important to separate the health effects of these opposite approaches for consuming a beverage containing alcohol; putting all subjects into groups based only on the grams of alcohol consumed over a period, usually a week, does not take into account the important differences associated with the pattern of drinking.

We are finally appreciating that we are much further along in our research on alcohol and health than the innumerable studies that have focused just the amount of alcohol consumed, or on the J-shaped curve.  We now realize the importance of the pattern of drinking.  This constitutes not only the type of beverage and frequency of drinking, but also the consumption of alcohol with food and the absence of binge drinking.  The pattern of drinking appears to be as important as, or even more important than, the quantity of alcohol consumed.

For the full critique of this paper by the International Scientific Forum on Alcohol Research, please click here.

Critique 235 –  Does type of alcohol or drinking pattern explain greater adverse effects of alcohol consumption among lower socio-economic subjects?    15 January 2020

Reference:  Gartner A, Trefan L, Moore S, Akbari A, Paranjothy S, Farewell D.  Drinking beer, wine or spirits – does it matter for inequalities in alcohol-related hospital admission? A record-linked longitudinal study in Wales.  BMC Public Health 2019;19:1651.   https://doi.org/10.1186/s12889-019-8015-3

The authors of this paper aimed to investigate whether and to what extent consumption by beverage type, BMI, smoking and other factors explain inequalities in alcohol-related harm evidenced though wholly attributable alcohol-related hospital admissions (ARHA).  They especially evaluated levels of socio-economic status (SES) as determined by geographic and individual levels of deprivation.  They based their analyses on data from 11,038 respondents to the Welsh Health Survey who answered questions on their health and lifestyle.

The results of this study support previous research on how factors associated with poor socio-economic status relate to poor health outcomes. It provides added information by providing an expanded definition for deprivation (assessed from geographic area of residence as well as from personal data), and for potential differences by type of beverage consumed.  The definition of deprivation included many factors that, together, seem to be the primary reason why poorer, less educated people seem to have more adverse health effects that have been attributed to alcohol consumption.

Specifically, this study shows that the amount of alcohol consumed by people with low SES may be only a minor factor in explaining their increase in adverse effects that are usually classified as being “alcohol-related.”   In this study, the frequency of alcohol consumption explained only 4% of the greater number of “wholly attributable alcohol-related hospital admissions.”  Co-existing other behaviors and conditions, especially smoking, obesity, living in a deprived environment, poor health status, and mental health, appeared to have much greater effect.  Thus, the conclusions of this study suggest that even for what are referred to as “wholly attributable .alcohol-related hospital admissions,” other factors associated with low SES may be more important than alcohol consumption itself as determinants of such adverse health outcomes.

For the full critique of this paper by the International Scientific Forum on Alcohol Research, please click here.

Critique 216 – Strong effects of five lifestyle factors on risk of mortality and longevity of life   –  31 May 2018

Reference: Li Y, Pan A, Wang DD, Liu X, Dhana K, Franco OH, Kaptoge S, Di Angelantonio E, Stampfer M, Willett WC. Hu FB.  Impact of Healthy Lifestyle Factors on Life Expectancies in the US Population.  Circulation 2018;137:00–00. (Pre-publication).  DOI: 10.1161/CIRCULATIONAHA.117.032047.

It has long been known that a number of lifestyle factors – such as not smoking, being physically active, avoiding obesity – decrease the risk of many of the “diseases of ageing,” especially cardiovascular disease and cancer. The present paper from the Nurses’ Health Study and the Health Professionals Follow-up Study is especially important as it demonstrates the joint effects of five healthy factors on disease-specific and total mortality in very large cohorts of subjects. The “healthy lifestyle factors” evaluated were (1) never smoking, (2) body mass index of 18.5 to 24.9 kg/m2, (3) ≥30 min/d of moderate to vigorous physical activity, (4) moderate alcohol intake, and (5) a high diet quality score (upper 40%).  The similarity in education and other socio-economic factors of the subjects in these studies tends to reduce potential confounding by such factors.

There were more than 42,000 deaths in their cohorts during follow-up periods extending up to 34 years. The effects of these factors on subsequent risk of mortality were striking: for subjects meeting criteria for all five factors versus none, there was an 84% reduction in all-cause mortality, 65% less cancer mortality, and 82% less cardiovascular disease mortality. The overall effect was associated with 12 to 14 additional years of life after age 50 for subjects meeting criteria for all five factors.

Forum members consider this to be an excellent study, as it was based on data from very large cohorts of well-monitored subjects over many decades, with essentially full ascertainment of mortality. This study strongly suggests that the leading causes of premature death throughout the developed world are, to a large extent, preventable.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 213 – A meta-analysis on lifestyle factors, cardiovascular disease, and total mortality for a very large number of middle-aged and elderly women – 27 March 2018

Reference: Colpani V, Baena CP, Jaspers L, van Dijk GM, Farajzadegan Z, Dhana K, Tielemans MJ, Voortman T, Freak-Poli R, Veloso GGV, Chowdhury R, Kavousi M, Muka T. Franco OH. Lifestyle factors, cardiovascular disease and all-cause mortality in middle-aged and elderly women: a systematic review and metaanalysis.  European Journal of Epidemiology 2018; pre-publication.  https://doi.org/10.1007/s10654-018-0374-z

Overall, Forum members considered this to be a well-done paper that provides additional information on alcohol’s effects on CVD and mortality among a very large number of middle-aged or elderly women. Although women markedly increase their risk of CVD following menopause, this is a group of women for whom data are sparse.  Weaknesses of the analysis include a lack of information on the pattern of drinking (binge versus regular), type of beverage, and drinking alcohol with or without food.  It is of note that in some of the studies included in the meta-analysis, factors such as HDL-cholesterol and fibrinogen were adjusted for in the study; given that these are mechanisms of alcohol’s effects, overall results will surely underestimate the effects.  Further, as the authors point out, this study provides little information on the physiologic mechanisms of alcohol’s effects on health.

Forum members praised the authors for this meta-analysis of a very large dataset. It strengthens previous analyses that show that each of the lifestyle factors considered – not smoking, not becoming obese, being physically active, and regularly consuming small to moderate amounts of alcohol – benefit health.  The more healthy lifestyle factors a subject has, the greater the benefit.

It will be especially important that future research evaluates what happens if subjects change their lifestyle habits, as such results would help target specific behavioral changes.  There are very limited data available on this at present, but such studies that have been done suggest that the onset of moderate drinking among non-drinkers, or a slight increase in alcohol consumption among light drinkers, have beneficial effects on health.  Still, it is appreciated that moderate alcohol consumption is only one of a number of factors making up a “healthy lifestyle,” which is clearly associated with less cardiovascular and other diseases and a much lower risk of mortality.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here. 

Critique 201 – The marked effect of lifestyle on mortality  —  26 June 2017

Reference: Larsson SC, Kaluza J, Wolk A.  Combined impact of healthy lifestyle factors on lifespan: two prospective cohorts.   J Int Med 2017.  Pre-publication.  Doi: 10.1111.joim.12637.

The aim of the present study was to examine differences in the risk of mortality and in survival associated with a healthy lifestyle versus a less healthy lifestyle. The analyses were based on a total of more than 60,000 Swedish men and women who were followed in one of two studies; at baseline, the subjects were aged 45 to 83 years and were free of cancer and cardiovascular disease.  The goal was to evaluate the effects of four “healthy” lifestyle factors: (1) nonsmoking; (2) physical activity at least 150 min/week; (3) alcohol consumption of 0–14 drinks/week; and (4) a healthy diet, with the latter defined as a modified Dietary Approaches to Stop Hypertension (DASH) Diet score above the median.   Cox proportional hazards regression models and Laplace regression were used to estimate respectively hazard ratios of all-cause mortality and differences in survival time.

The authors report: “Compared with individuals with no or one healthy lifestyle factor, the multivariable hazard ratios of all-cause mortality for individuals with all four health behaviors were 0.47 (95% confidence interval [CI] 0.44-0.51) in men and 0.39 (95% CI 0.35-0.44) in women. This corresponded to a difference in survival time of 4.1 (95% CI 3.6-4.6) years in men and 4.9 (95% CI 4.3-5.6) years in women.”

Forum members considered this to be a well-done study on a large cohort with complete follow-up data on mortality. Notable weaknesses included the fact that never drinkers and consumers of 0 to 14 drinks/week were considered in one group (thus, including lifetime abstainers, ex-drinkers, and current moderate drinkers); these subjects were compared with consumers of >14 drinks/week.  Thus potential differences between abstinence versus light/moderate consumption could not be determined.  Further, there were incomplete data on the pattern of drinking, and no data on the type of beverage consumed were reported.  Nevertheless, the reduction in mortality for subjects following a healthy lifestyle was impressive: a reduction by half, or more, in the risk of mortality and a 4- to 5-year longer lifespan.

Based on a number of previous studies that evaluated similar lifestyle factors and mortality, the results of this study were not unexpected. Still, they strongly support the remarkable effects on mortality and survival of these lifestyle factors.  While not smoking was clearly the factor with the strongest effect on reducing mortality, having a healthy diet, exercising, and consuming light to moderate amounts of alcohol all make additional contributions.  This is an important message in that even individuals who may be challenged by genetic or socioeconomic predispositions to earlier demise, adopting certain lifestyle habits can help them reach their greatest potential for a longer and healthier lifespan.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 189 – Importance of drinking pattern on the effects of wine on health —  26 July 2016

Reference:  Boban M, Stockley C, Teissedre P-L, Restani P, Fradera U, Stein-Hammer C, Ruf J-C.  Drinking pattern of wine and effects on human health: why should we drink moderately and with meals?  Food Funct 2016;7:2937–2942. DOI:10.1039/c6fo00218h

A review article appearing in Food & Function, a publication of the Royal Society of Chemistry in the United Kingdom, presents a summary of evidence-based scientific data relating the moderate consumption of wine and other alcoholic beverages to health. Forum members considered the paper to be a well-thought-out appraisal of the effects that the pattern of consumption (e.g., the type of beverage, regular versus binge drinking, consumption with meals, etc.) affects its risks and benefits.  (It is recognized that some of the authors of this publication work primarily with wine, but the review article covers key behaviors that affect the relation of the consumption of all types of alcohol to health.)

The authors describe how the polyphenols and other non-alcoholic components of wine provide anti-oxidants and decrease post-prandial oxidative stress. These phenols can also scavenge free radicals in the mouth and throughout the gastro-intestinal tract, preventing lipid peroxidation as well as the absorption of cytotoxic lipid peroxidation products.  Wine also favorably affects urate levels; thus, the antioxidant activity is apparently influenced by two separate mechanisms: wine-derived phenolic compounds and plasma urate.  A further important biological property of wine is its potent antimicrobial activity that tends to decrease adverse effects of food-borne and oral pathogens.

The article summarizes the key differences in health effects when alcohol (especially wine) is consumed moderately, with food, and on a regular basis rather than in binges. These differences emphasize why evaluating only the total amount of alcohol consumed, and not how it is consumed, is inadequate when evaluating its effects on health and disease.  Further, the authors emphasize how all medical and scientific information concerning the effects of wine and alcohol consumption on human health should be evidence-based and communicated in a competent, credible and unbiased manner.

Note on potential conflict of interest:   While several of the authors of this paper are members of our Forum, they have had no input into the review of the article.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 170 – An update on the association of alcohol consumption with the risk of cancer  —  1 September 2015

Reference:  Cao Y, Willett WC, Rimm EB, Stampfer MJ, Giovannucci EL.  Light to moderate intake of alcohol, drinking patterns, and risk of cancer: results from two prospective US cohort studies.  BMJ 2015;351:h4238; doi: 10.1136/bmj.h4238

This well-done analysis based on data from two very large cohort studies, the Nurses’ Health Study and the Health Professionals’ Follow-up Study, evaluated the association of alcohol consumption over many years with the risk of cancer.  The authors conclude that men reporting an average intake of more than 15 grams of alcohol per day, but not less, have a significant increase in risk of alcohol-related cancers.  In women, however, even the consumption of an average of 5.0 – 14.9 grams of alcohol per day (the equivalent of between ½ and 1 ½ typical drinks) was associated with a slight increase in total cancer risk, stated to be primarily from an increase in the risk of breast cancer.  For both genders, there seemed to be a dose-response increase in risk of cancer with larger amounts of alcohol.  At the same time, smoking was identified as an even more important risk factor than alcohol for these cancers.

Forum members considered this to be an important study presenting data that are of relevance to individuals and agencies providing advice regarding alcohol consumption.  There is little question that heavy drinking markedly increases the risk of upper aero-digestive cancers, and no physician or agency advises people to consume in excess of the typical limits of no more than one or two drinks/day.  Hence the finding in this study of an increase in some cancers among women (especially breast cancer) even for lighter drinking has implications for alcohol policy.

The Forum was disappointed that all dietary and other lifestyle factors that have been shown to increase the risk of cancer (data that are known to be available to these investigators) were not included in their report.  Members were especially concerned that the net effects on health and mortality of light-to-moderate alcohol consumption were not commented upon in the paper.  Given that the risk of the most common causes of death, especially cardiovascular diseases, are reduced by moderate drinking, it seems that the authors should have included data, or at least mentioned, the effects of alcohol on cancer mortality and, especially, on total mortality.  It has recently been emphasized that cohort studies that report on only one outcome (in this case, cancer) but do not mention other outcomes that are affected by the same exposure, especially total mortality, do not present the full picture, and can lead to biased recommendations. The inclusion of such information from these cohorts could provide even more valuable data upon which to develop appropriate guidelines for alcohol use by individual patients and the public.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 164 – Why are the harmful effects of alcohol consumption greater among people with low education and income? —  14 May 2015

Reference: Jones L, Bates G, McCoy E, Bellis MA.  Relationship between alcohol-attributable diseaseand socioeconomic status, and the role of alcohol consumption in this relationship: a systematic review and meta-analysis.  BMC Public Health 2015;15:400.  DOI 10.1186/s12889-015-1720-7.

Epidemiologists have noted for many years that one of the key factors that modifies the relation between alcohol intake and many diseases is the education, income, or other index of socio-economic status (SES) of subjects.  While differences in drinking practices (regular moderate versus binge drinking), other more moderate lifestyle factors, better access to health care, etc., have been suggested as potential mechanisms, there has been little research directed at this relation.

The present study is a systematic review of published reports to investigate the relationship between SES and risk of mortality or morbidity for each alcohol-attributable condition and, where feasible, to explore alcohol consumption as a mediating or interacting variable in this relationship.  It summarized data from 31 case-control or cohort studies, relating an overall measure of the effects of low SES (variously defined) to the risk of cancers related to alcohol, as well as to liver disease, hypertension, stroke, epilepsy, cardiac arrhythmias, and pancreatitis.

The key findings of the study demonstrate a tendency for greater risk for low-SES subjects than for high-SES subjects to develop a number of diseases that are associated with alcohol consumption.  Specifically, the authors report higher and statistically significant increases in risk of head and neck cancer and of stroke associated with alcohol consumption among lower-SES subjects than among higher-SES subjects.  There was a tendency for lower risk of breast cancer among lower-SES women, but differences were not significant when adjusted for known confounders.  The authors suggest that some of the effects shown may relate to greater total amounts of alcohol consumption by lower-SES subjects, or due to their higher levels of smoking.

Forum members thought this was a valiant attempt of the authors to unravel what has been a mystery: why do people at lower levels of SES seem to have more adverse effects of alcohol consumption than subjects at higher levels of SES.  Unfortunately, as the authors admit, current scientific data do not allow firm answers.  Suggested theories for reasons why low-SES subjects may have more adverse effects from alcohol include (1) different drinking patterns, with more binge drinking, (2) clustering of poor lifestyle factors, and (3) less access to health care.  In some studies, even though the reported total alcohol intake of low- and high-SES subjects may be similar, the latter seem more likely to drink moderate amounts of alcohol on a regular basis, while lower-SES subjects are more likely to binge drink on fewer days per week.  However, other studies do not support such a finding.  Further, there may be differences according to the type of alcoholic beverage consumed, which was not considered in this study.

Forum members pointed out that differences in factors other than drinking patterns probably contribute to the greater adverse effects among subjects with lower SES.  One member suggested that lower SES affects susceptibility to many diseases, most likely due to effect modification of hitherto unrecognized factors.  The Forum concluded that there are too many confounders to make a conclusion about this topic, and much more research will be needed to understand how socio-economic factors affect the risk of disease and may modify the relation between alcohol consumption and disease.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 156 – The pattern of alcohol consumption and risk of cirrhosis  —  10 February 2015 

Reference:  Askgaard G, Grønbæk M, Kjær MS, Tjønneland A, Tolstrup JS.  Alcohol drinking pattern and risk of alcoholic liver cirrhosis:  A prospective cohort study. Pre-publication.  J Hepatol (2015)   http://dx.doi.org/10.1016/j.jhep.2014.12.005.

This paper, from a group of experienced investigators in Denmark using data from a large population-based cohort, attempted to judge how drinking pattern affects the risk of a subject developing alcoholic cirrhosis.  From a cohort study of 55,917 participants (aged 50–64 years), the authors calculated hazard ratios (HRs) for alcoholic cirrhosis in relation to drinking frequency, lifetime alcohol amount, and beverage type.  A total of 342 subjects developed alcoholic cirrhosis.  The authors concluded that, in men, daily drinking was associated with an increased risk of alcoholic cirrhosis as compared with less frequent consumption; they also concluded that wine consumption might be associated with a lower risk of alcoholic cirrhosis that associated with the consumption of beer or liquor.

The major concern of Forum reviewers regarding this paper was the use of a diagnosis of “alcoholic cirrhosis” to judge the effects of alcohol on the disease; this was considered a type of circular reasoning.  A diagnosis of alcoholic cirrhosis generally requires a history of alcoholism or heavy drinking, and subjects given that diagnosis would essentially be limited to those who were heavy drinkers.  Thus, it would be no surprise to find a history of heavy drinking when evaluating alcohol as an exposure.

There was also concern about the implications of the author regarding frequency of drinking.  The authors’ described in detail the relation of drinking pattern to liver cirrhosis, differentiating, in particular, effects associated with drinking daily versus drinking on 4-5, or 6 days a week.  However, Forum members were concerned that as the overall average amount of alcohol for the daily drinkers exceeded that of those drinking less frequently, it was difficult to know if it was primarily the frequency of drinking (as concluded by the authors) or the total amount of alcohol consumed by subjects. The authors stated that they wanted to “execute evidence-based counselling,” which of course is praiseworthy, but Forum members had difficulty understanding why the effect of drinking 5-6 days/week should differ much from 7 days/week, especially if the usual amount was moderate.  Indeed, the investigators state: “The mean alcohol amounts for daily drinkers were somewhat higher compared to those drinking less frequently in each category of alcohol amount, making it difficult to detangle the effect of drinking frequency and alcohol amount.”  Forum members noted that the authors conclude that “daily drinking” was associated with increased cirrhosis, but they do not state daily drinking of how many drinks, which would be especially important. The study did not provide reliable data that would support alcohol-free days during the week.

The referent group in this study was made up of subjects reporting < 0 to 14 drinks/week, which would consist of light-to-moderate drinkers, those considered to be “sensible drinkers” in most cultures.  Hence, it is no surprise that as subjects reported greater amounts of alcohol in the study, the risk of alcoholic cirrhosis increased.  No one advises people to drink more than sensible limits. Further, there was a much higher risk of of cirrhosis among “current abstainers” than in the referent group, undoubtedly indicating that the current abstainers group included many former heavy drinkers.

Overall, the Forum thought that this paper raises, but does not answer, a number of questions about the relation of alcohol to the risk of cirrhosis: (1) Is wine really less liver-toxic than beer or liquor?  (2) Should we really tell everyone to have one day each week without wine being included with their meal, or on which to avoid any alcohol?  (3)  Why is daily drinking, rather than 5 or 6 days per week dangerous for men but tends to be even slightly protective in women regarding liver disease?  Because of concerns due to problems with bias from the diagnostic approach, the probability of under-reporting of alcohol consumption, and the lack of biological plausibility, we will need further scientific data to answer these important questions.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 150 –  A new meta-analysis on the relation of alcohol consumption to the risk of ischemic heart disease  –  6 November 2014

Reference: Roerecke M, Rehm J.  Alcohol consumption, drinking patterns, and ischemic heart disease: a narrative review of meta-analyses and a systematic review and meta-analysis of the impact of heavy drinking occasions on risk for moderate drinkers. BMC Medicine 2014;12:182.

This meta-analysis is from authors who in the past have tended to argue that the demonstrated inverse association between moderate alcohol consumption and ischemic heart disease (IHD) shown in most studies is due to confounding by other lifestyle factors.  However, in this paper, they come to the conclusion (in their words): “Results from our quantitative meta-analysis showed that drinkers with average intake of < 30 g/day and no episodic heavy drinking had the lowest IHD risk (relative risk = 0.64, 95% confidence interval 0.53 to 0.71).  Drinkers with episodic heavy drinking occasions had a risk similar to lifetime abstainers (relative risk = 1.12, 95% confidence interval 0.91 to 1.37).”

The conclusions of the authors thus not only support a “J-shaped” curve for alcohol consumption and IHD but provide additional support suggesting that the effect may be causal, i.e., related to the alcohol consumption and not to other associated lifestyle factors.  They state: “For drinkers having one to two drinks per drinking day without episodic heavy drinking, there is substantial and consistent evidence from epidemiological and short-term experimental studies for a beneficial association with IHD risk when compared to lifetime abstainers.  The alcohol-IHD relationship fulfills all criteria for a causal association proposed by Hill.”

It is clear from epidemiologic studies that moderate drinkers may exhibit moderation in other lifestyle factors (such as not smoking, eating a healthy diet, etc.).  Indeed, there is aggregation of healthy lifestyle factors that must be considered when judging how a single factor (such as moderate drinking) relates to disease outcomes.  This meta-analysis suggests that other lifestyle factors do not explain the lower risk of IHD found to occur among moderate drinkers.  In fact, increasingly, moderate drinking is found to be an independent (and rather important) lifestyle factor that lowers the risk of cardiovascular disease, regardless of other factors.  Such protection is not seen when drinking is more than moderate, defined in this paper as an average of 30 grams or more of alcohol per day, the equivalent of about 2 ½ to 3 typical drinks.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 124 – The J-shaped curve for the relation of alcohol consumption to mortality  —  17 September 2013

Reference:  Plunk AD, Syed-Mohammed H, Cavazos-Rehg P, Bierut LJ, Grucza RA.  Alcohol consumption, heavy drinking, and mortality: Rethinking the J-shaped curve.  Alcohol Clin Exp Res 2013;pre-publication: DOI: 10.1111/acer.12250

An analysis based on data from more than 110,000 subjects in the USA, of whom 3,364 died during a follow-up period of up to 9 years, was used to evaluate the relation of “heavy drinking” and “nonheavy drinking” to the risk of all-cause mortality.  The authors defined heavy drinking as 5 or more drinks/occasion, and recorded the frequency in which subjects consumed such amounts.  Subjects consuming < 5 drinks/occasion were classified as nonheavy drinkers.

The key findings of the analyses were that there was a positive and linear increase in risk of mortality for subjects consuming heavy amounts of alcohol, with the risk increasing as drinking at this level was more frequent.  For nonheavy drinkers, there was a J-shaped relation with mortality.  The point at which the nonheavy drinkers’ risk of mortality exceeded that of abstainers was between 4 and 5 drinking occasions/week.

Forum reviewers thought that this was a well-done analysis that emphasizes the importance of the pattern of drinking, and not just the average weekly intake.  Although the upper limits of drinks/occasion exceeded that usually considered as “moderate,” a J-shaped curve between alcohol and mortality for these drinkers was demonstrated.  This is the pattern usually seen in prospective epidemiologic studies when “moderate” is defined at somewhat lower levels of alcohol intake.

Forum reviewers agreed with the conclusions of the authors regarding the importance of considering the pattern of drinking when evaluating the health effects of alcohol.  The authors concluded: “Promoting less harmful drinking patterns by reducing heavy drinking frequency is an appropriate harm reduction strategy, and assessing drinking pattern by determining the frequency of heavy and nonheavy drinking is a simple and fast way to determine risk and promote less risky drinking behavior.”

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 121 – Differences between wine and other alcoholic beverages in terms of adverse consequences of alcohol consumption  –  22 August 2013

Reference:  Dey M, Gmel G, Studer J, Dermota P, Mohler-Kuo M.  Beverage preferences and associated drinking patterns, consequences and other substance use behaviours.  European Journal of Public Health 2013; advance access; doi:10.1093/eurpub/ckt109

Questionnaire-based data on alcohol consumption were collected from more than 5,000 military recruits in Switzerland, who had a mean age of just over 19 years.  There were very few drinkers who averaged more than 21 drinks/week, so the emphasis was on the effects of what is usually referred to as “binge drinking,” defined in this study as the consumption of 6 or more typical drinks (a drink containing 10-12 g of alcohol) on a single occasion.  The “preference” of one particular type of beverage was based on the subject indicating that it made up more than two-thirds of his total alcohol consumption.  The specific type of beverage preferred — beer, wine, or “other beverages” (the latter including apertifs, “pops,” chillers, and coolers) — was related to the pattern of drinking (frequency of binge drinking) and to the reported occurrence of adverse alcohol-related consequences (e.g., blackouts, driving after heavy drinking, missing work due to drinking, accidents, unprotected sex, encounters with police).

The authors report: “Preference for beer was associated with risky drinking patterns and, comparable with a preference for strong alcohol, with the use of illicit substances (cannabis and other illicit drugs).  In contrast, a preference for wine was associated with low-risk alcohol consumption and a reduced likelihood of experiencing at least four negative alcohol-related consequences or of daily cigarette smoking.”  More frequent binge drinking of any beverage was strongly associated with an increase in adverse alcohol-related consequences.

Forum reviewers thought that the adverse outcomes, especially those related to heavy beer intake, tend to characterize a particular subculture that demonstrates problematic substance use due to personal characteristics of the subjects.  The unhealthy outcomes may be a feature more of the cultural habits of the subjects rather than just due to the type of beverage they consume most frequently.

The authors conclude that strategies for preventing problems with alcohol abuse should attempt to reduce excessive drinking of all types of beverages.  However, they add: “to lessen the additional negative effects of beer and strong alcohol, which are particularly cheap in Switzerland, targeted strategies such as minimum pricing policies for these beverage types should be considered.”  Forum members think that the extent to which such beverage-specific price restructuring would decrease unhealthy drinking practices among young people remains unclear.

For the full critique of this critique by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 110 – Divergent effects of regular moderate and binge drinking – 30 April 2013

Reference:  Graff-Iversen S, Jansen MD, Hoff DA, Høiseth G, Knudsen GP, Magnus P, Mørland J, Normann PT, Næss ØE, Tambs K.  Divergent associations of drinking frequency and binge consumption of alcohol with mortality within the same cohort.  J Epidemiol Community Health 2013;67:350-357. doi:10.1136/jech-2012-201564.

The present study relates alcohol consumption measured in young to middle-aged adults to mortality over a follow-up period of 20 years.  The analyses are based on data from a large population in a region of Norway where the alcohol drinking pattern most commonly reported was binge drinking on infrequent occasions.  Previous research has demonstrated that a very different drinking pattern – the frequent consumption of small amounts of alcohol – is generally considered to be the pattern associated with most health benefits.

In the present study, both men and women who reported consuming alcohol up to twice a month had about 20% lower mortality than did abstainers.  All groups reporting binge drinking had higher mortality than non-binge drinkers (which was statistically significant for men and had a similar estimated effect among women).  Cardiovascular and ischemic heart disease mortality had similar patterns as total mortality, being lower among drinkers but higher among those who reported binge drinking.

The key finding of this study is that there are divergent effects on mortality of the frequency of drinking and the amount of alcohol consumed per occasion.  While the results for this study may reflect a certain Northern European pattern of drinking (not frequent but heavy on each occasion), they may not apply to other European or North American populations, where drinking is more frequent but binge drinking less common.  Nevertheless, the results of this study support results typically found in more moderately drinking populations: more frequent drinking, but smaller amounts per occasion, is the pattern of alcohol consumption associated with the lowest risk of mortality.  Both aspects of drinking must be considered when studying the relation of alcohol to mortality.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 102 –  Possible prevention of myocardial infarction from alcohol’s effects on periodontal disease: An hypothesis   –   6 February 2013

Reference: Håheim LL, Olsen I, Rønningen KS.  Oral infection, regular alcohol drinking pattern, and myocardial infarction.  Medical Hypotheses 2012;79:725–730.

A cross-sectional analysis among more than 5,000 Norwegian men was designed to determine if the frequency of alcohol consumption related to the risk of myocardial infarction associated with infectious periodontal disease.  The authors hypothesized that because it is bactericidal, frequent alcohol consumption would decrease periodontal infection and lower the risk of tooth extraction related to periodontal infection.  The authors state that their main finding was that frequent drinking lowers the risk of MI associated with periodontal disease.

Forum reviewers had real concern about the paper and the conclusions of the authors.  Some stressed that the per cent of alcohol in most “drinks” is too low to be really bactericidal, that the key exposures (alcohol and oral infections) were based exclusively on self report and did not have information on type of beverage or pattern of drinking, that many confounders (especially related to socio-economic status) were not adequately taken into consideration, and that the authors did not really test the results of their study with appropriate statistical testing.

Current scientific data show an increase in the risk of cardiovascular disease to be associated with periodontitis.  Further, data consistently show a decrease in the risk of cardiovascular disease from moderate drinking, and a very large number of mechanisms have been identified.   However, the present study does not confirm that alcohol consumption plays an important role in preventing heart disease through its effect on periodontitis.

For the full critique of this article by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 083 – Higher indices of quality of life are seen among persistent moderate drinkers than among abstainers  —  20 June 2012

Reference:  Kaplan MS, Huguet N, Feeny D, McFarland BH, Caetano R, Bernier J, Giesbrecht N, Oliver L, Ross N.  Alcohol Use Patterns and Trajectories of Health-Related Quality of Life in Middle-Aged and Older Adults: A 14-Year Population-Based Study.  J. Stud Alcohol Drugs 2012;73:581–590.

Data from a nationally representative sample of 5,404 community-dwelling Canadians ages 50 and older at baseline (1994/1995) was used to estimate the effects of alcohol drinking patterns on indices of quality of life, at baseline (when subjects were aged ≥50 years) and after a follow-up period.  Health-related quality of life was assessed with the Health Utilities Index Mark 3 (HUI3).  The authors report that most participants showed stable alcohol-consumption patterns over 6 years.  Persistent regular moderate drinkers had the highest indices of quality of life at baseline, but subsequent changes in HUI3 were similar in all groups except those reporting decreasing alcohol consumption.  The investigators conclude that persistent moderate drinkers had higher initial levels of health-related quality of life than persistent nonusers and those in other groups.  However, rates of decline over time were similar for all groups except those decreasing their consumption, which had a greater decline in their level of health-related quality of life than  persistent moderate users. While Forum reviewers admired the intent of this study, there were concerns about some of the statistical and epidemiologic aspects.  The reasons that some people stopped drinking or decreased their intake were not known; while the authors state that subjects decreasing their alcohol consumption had a more rapid decline in quality of life measures, it is not known what percentage of such subjects decreased alcohol intake due to the development of serious  iseases.  If this were the case, such diseases may have been more important in their subsequent adverse health than the change in their drinking habits.

Further, the “baseline” quality of life measures in this study were obtained when subjects were aged 50 or older; this baseline value of quality of life was higher in moderate drinkers.   However, there are statistical problems if adjustments are made for this when quality of life is assessed subsequently and related to drinking pattern.  Peto has described this problem as a “horse-racing effect.”  He states that in prospective studies, the correlation between exposures (e.g., drinking pattern)  and outcomes (e.g., quality of life) assessments during follow up are likely to be the same as the outcome at the end of follow up.  As an analogy he uses a race between ‘slow’ and ‘fast’ horses; it is likely that the fast horses will be ahead at the mid-point of the race as well as at the end.  Environmental effects on quality of life begin early in life, and if one adjusts for the mid-life value (as done and referred to as “baseline” in the present study), you may end up disregarding much of the effect of subsequent alcohol intake.

Overall, this study shows a positive relation between moderate alcohol intake and quality of life in middle-aged adults.  The effects on the subsequent quality of life as one ages of continued alccohol consumption, or of decreasing intake, remain unclear.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 057 – Differences in effects on atherosclerosis of regular moderate drinking and binge drinking.   An experimental study in mice.           20 September 2011

Reference:  Liu W, Redmond EM, Morrow D, Cullen JP.  Differential effects of daily-moderate versus weekend-binge alcohol consumption on atherosclerotic plaque development in mice.  Atherosclerosis 2010, doi:10.1016/j.atherosclerosis.2011.08.034

An excellent study among experimental animals has reported very dramatic differences between the effects of alcohol administered in moderation on a daily basis and the same total weekly amount of alcohol administered on only two days of the week: binge drinking.  The mice used in the study that were given regular moderate amounts of alcohol showed no weight gain, improved lipid values, and much less development of atherosclerosis than did control animals.  However, those given alcohol in a binge-drinking pattern showed worse outcomes than control animals, and much worse outcomes than those given regular moderate alcohol.

This experimental study provides strong support for the frequent finding among humans in epidemiologic studies: benefits from regular moderate drinking, adverse effects from binge drinking.  It is especially important since, being an experimental study, the potential confounding effects of other lifestyle habits are not an issue, as is always the case for observational studies among humans.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 043 – Frequent moderate drinking of alcohol is associated with a lower risk of fatty liver disease – 23 May 2011

Reference:  Hiramine Y, Imamura Y, Uto H, Koriyama C, Horiuchi M, Oketani M, Hosoyamada K, Kusano K, Ido A, Tsubouchi H.  Alcohol drinking patterns and the risk of fatty liver in Japanese men.  J Gastroenterol 2011 46:519–528.  DOI 10.1007/s00535-010-0336-z.

In a large study of men in Japan, the presence of fatty liver disease by ultrasonography showed an inverse association with the frequency of alcohol consumption; there was some suggestion of an increase in fatty liver disease with higher volume of alcohol consumed per day.  Moderate drinkers had lower levels of obesity than did non-drinkers, and both obesity and metabolic abnormalities were positively associated with fatty liver disease.

These findings support the results of a number of other recent studies showing that moderate drinking does not increase the risk of this common type of liver disease; instead, it is associated with a lower risk of its occurrence.  We agree with the implications of these studies as stated by the authors: “These results suggest that lifestyle modifications aimed at fighting central obesity and metabolic abnormalities should be the most important recommendations for the management of fatty liver.  In addition, it seems unlikely that the risk of fatty liver can be reduced by the discontinuation and/or reduction of alcohol consumption alone.”

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 028 – Changes over time in relation of social class to mortality from cirrhosis. 9 January 2011

Reference:  Crombie IK, Precious E.  Changes in the social class gradient of cirrhosis mortality in England and Wales across the 20th century.  Alcohol and Alcoholism 2011;46:80–82.

To explore the nature of the social class gradient of cirrhosis mortality in England and Wales across the 20^th century, data on male cirrhosis mortality by social class were obtained from the Registrar General’s Decennial Supplements for the years 1921–1991. This paper describes a dramatic change during the 20th century in the association between social class and mortality from liver cirrhosis.  While deaths from cirrhosis were more common among higher social classes in the early part of the century, the pattern changed so that deaths from cirrhosis were much more common among the lower social classes by the end of the century.

Suggested reasons for the lower current rates among subjects at higher social class include different patterns of alcohol consumption, with regular moderate consumption (especially of wine with meals) becoming more common with higher social class subjects while binge drinking (especially of beer and spirits) remaining more common in lower social classes.  However, a number of other factors may relate to the class differences in rates of hepatic cirrhosis, including a less healthy diet and greater rates of obesity (associated with hepatic fatty liver and cirrhosis) among lower social class subjects and social class differences in hepatitis rates.  Further, certain medications, coffee consumption, and many other lifestyle factors are associated with hepatic cirrhosis.  The actual reasons for the changes over time reported in this paper remain unclear.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 025 – Pattern of drinking and type of beverage affect the relation of alcohol intake to coronary heart disease. 1 December 2010

Reference: Ruidavets J-B, Ducimetièere P, Evans A, Montaye M, Haas B, Bingham A, Yarnell J, Amouyel P, Arveiler D, Kee F, Bongard V, Ferrières J.  Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME).  BMJ 2010;341:c6077 doi:10.1136/bmj.c6077.

Using cohort data from Belfast and France, investigators related weekly alcohol consumption, incidence of binge drinking (alcohol >50 g on at least one day a week), incidence of regular drinking (at least one day a week, and alcohol <50 g if on only one occasion), volume of alcohol intake, frequency of consumption, and types of beverage consumed to risk of coronary heart disease (CHD) events over a 10 year follow-up period.  Overall, 60.5% of subjects from N. Ireland and 90.6% of French reported drinking alcohol at least once a week.  Among drinkers, 12% of men in Belfast drank alcohol every day compared with 75% of men in France.  Mean alcohol consumption was 22.1 g/ day in Belfast and 32.8 g/day in France.  Binge drinkers comprised 9.4% and 0.5% of the Belfast and France samples, respectively.

Results showed that, after multivariate adjustment, the hazard ratio for hard coronary events compared with regular drinkers was 1.97 (95% CI 1.21 – 3.22) for binge drinkers, 2.03 (95% CI 1.41 – 2.94) for never drinkers, and 1.57 (95% CI 1.11 – 2.21) for former drinkers.  The hazard ratio for hard coronary events in Belfast compared with in France was 1.76 (95% CI 1.37 to 2.67) before adjustment, and 1.09 (95% CI 0.79 to 1.50) after adjustment for alcohol patterns and wine drinking.  Only wine drinking was associated with a lower risk of hard coronary events, irrespective of the country.

The authors conclude that regular and moderate alcohol intake throughout the week, the typical pattern in middle-aged men in France, is associated with a low risk of ischemic heart disease, whereas the binge drinking pattern more prevalent in Belfast confers a higher risk.  While a strong inverse association between moderate alcohol consumption and cardiovascular disease has been demonstrated for decades, more recent research has emphasized the importance of the pattern of drinking (regular moderate versus episodic or binge drinking).  Further, there continues to be debate about the potential greater effect of wine versus other beverages containing alcohol.  This study shows that regular moderate drinking (especially of wine) is associated with lower risk of MI, but episodic or binge drinking (especially of beer or whiskey) increases the risk.  Lifetime abstinence has a similar adverse relation to CHD as does episodic or binge drinking.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 022 –  Alcohol consumption decreases with the development of disease 21 November 2010

Reference:  Liang W, Chikritzhs T.  Reduction in alcohol consumption and health status.  Addiction 2010; in press (doi:10.1111/j.1360-0443.2010.03164.x).

In a cross-sectional study from the 2004 and 2007 Australian National Drug Strategy Household (NDSH) surveys, respondents were questioned about their current and past drinking, the presence of formal diagnosis for specific diseases (heart disease, type 2 diabetes, hypertension, cancer, anxiety, depression) and self-perceived general health status.  The sample sizes for the 2004 and 2007 NDSH surveys were 24,109 and 23,356, respectively.

The authors report that respondents with a diagnosis of diabetes, hypertension, or anxiety were more likely to have reduced or stopped alcohol consumption in the past 12 months. The likelihood of having reduced or ceased alcohol consumption in the past 12 months increased as perceived general health status declined from excellent to poor (although the authors do not point out that lifetime abstainers were more likely than moderate drinkers to report less than excellent health status).

The authors conclude that the experience of ill health is associated with subsequent reduction or cessation of alcohol consumption (“sick quitters), which is consistent with most prospective epidemiologic studies.  The authors also conclude that this may at least partly underlie the observed ‘J-shaped’ function relating alcohol consumption to premature mortality.  On the other hand, most modern epidemiologic studies are careful not to include “sick quitters” within the non-drinking category, and relate health effects of drinkers with those of lifetime abstainers.  Further, prospective studies in which alcohol intake is assessed at different times (rather than having “changes” based only on recall at one point in time, as was done in this study) usually indicate that subjects who decrease their intake are more likely to subsequently develop adverse health outcomes, especially related to cardiovascular disease, than those who continue moderate drinking.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 017 – Moderate alcohol intake is associated with a lower risk of total mortality than are either abstinence or heavy drinking. 5 September 2010

Reference:  Holahan CJ, Schutte KK, Brennan PL, Holahan CK, Moos BS, Moos RH.  Late-Life Alcohol Consumption and 20-Year Mortality.  Alcoholism: Clinical and Experimental Research 2010;34:in press, November 2010.

In a study based on data from 1,824 predominantly Caucasian Americans from the Western part of the United States, alcohol consumption at baseline was related to mortality risk during a 20-year follow-up period.  Subjects were recruited into a longitudinal project that has examined late-life patterns of alcohol consumption and drinking problems.  Lifetime abstainers were not included in the study, which focused on stress and coping processes among problem drinkers and non-problem drinkers.  The sample at baseline included only subjects aged 55 to 65 years who had had outpatient contact with a health care facility in the previous 3 years.

The database at baseline included information on daily alcohol consumption, sociodemographic factors, former problem drinking status, health factors, and social-behavioral factors.  Subjects who were not lifetime abstainers but did not report drinking at the time of the baseline examination were classified as “abstainers.”  Data on potential changes in alcohol consumption during the course of the study were not collected.  Death during follow up was confirmed primarily by death certificate.

The key results of the paper are that even when adjusting for sociodemographic factors, former problem drinking status, health factors, and social-behavioral factors, moderate drinking was associated with considerably lower risk of all-cause mortality.  In comparison with “moderate drinkers” (subjects reporting up to 3 drinks/day), abstainers had 51% higher mortality risk and heavy drinkers had 45% higher risk.  The study supports most previous scientific studies showing that moderate drinking, in comparison with both abstinence and heavy drinking, is associated with lower risk of total mortality.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 007 – People may change to a “healthier” pattern of drinking as they age. 9 June 2010

Reference :  Molander RC, Yonker JA, Krahn DD.  Age-related changes in drinking patterns from mid- to older age: results from the Wisconsin Longitudinal Study.  Alcoholism: Clinical and Experimental Research 2010;34 (Published early online 7 May 2010).

In a prospective longitudinal study of a cohort of Americans in the “Baby Boomer” generation, subjects’ drinking habits were assessed at two points, when they were approximately 53 years of age and again when they were approximately 64 years of age.  As the subjects got older, they began to consume fewer drinks per occasion but to consume alcohol more frequently; the net effect was little change in total alcohol intake for women but a slight increase for men.

In most epidemiologic studies, regular moderate drinking is the pattern associated with lower risk of many chronic diseases; hence, the described change in drinking pattern in this study (smaller amounts on more frequent occasions) can be considered a “healthy” change.  Most long-term observational studies show a decrease in total alcohol intake with ageing, although reasons for such are poorly understood.

This paper emphasizes the importance of knowing the pattern of drinking, and not just the total number of drinks consumed over a week, when evaluating the impact of alcohol consumption on health and disease.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 004 – Moderate alcohol consumption is associated with other healthy lifestyle factors. 24 May 2010

Reference: Hansel B, Thomas F, Pannier B, Bean K, Kontush A, Chapman MJ, Guize L, Bruckert E.  Relationship between alcohol intake, health and social status and cardiovascular risk factors in the urban Paris-Ile-De-France Cohort: is the cardioprotective action of alcohol a myth?  European J Clin Nutrition, advance online publication, doi:10:1038/ejcn.2010.61.

An analysis based on a very large number of subjects in France demonstrates, as have most other studies, that moderate consumers of alcohol have many associated healthy lifestyle habits: lower levels of body mass index, blood glucose, heart rate, stress and depression scores; higher subjective health status, HDL-cholesterol values, levels of physical activity and social status.   The authors suggest that alcohol is not related causally to any of these factors, and that the other lifestyle factors, not alcohol consumption, are the reason that moderate drinkers have less cardiovascular disease.  They chose a very narrow group of citations from the literature to support this contention.

The authors ignore a large number of well-conducted prospective epidemiologic studies showing that moderate drinkers are at lower risk over time of developing certain risk factors.  Further, the authors of this paper ignore an immense basic science literature that suggests that alcohol is an important factor in the development of biological risk factors, atherosclerosis, and cardiovascular disease.  Further, they do not describe a number of studies that have shown specifically that moderate drinking is associated with less cardiovascular disease and diabetes among subjects who are otherwise very healthy (non-smokers, not obese, physically active, and on a healthy diet).

There is no doubt that confounding by associated lifestyle factors can play a role in the lower risk of chronic diseases among moderate drinkers, who tend to also have other healthy behaviors.  However, there is now a large body of scientific evidence that indicates that alcohol is an important factor in the lower rates of such diseases; current scientific data do not support the conclusions of the authors of this paper.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.

Critique 003 – Moderate alcohol consumption markedly reduces the risk of diabetes mellitus, even among subjects with otherwise very healthy lifestyles. 17 May 2010

Reference:  Joosten MM, Grobbee DE, van der A DL, Verschuren WWM, Hendriks HFJ, Beulens JWJ.  Combined effect of alcohol consumption and lifestyle behaviors on risk of type 2 diabetes.  Am J Clin Nutr 2010;91: 1777-1783.

In a very well-done analysis from a large Dutch population, it was shown that moderate drinking considerably lowers the risk of developing type 2 diabetes even among subjects who are otherwise following a healthy lifestyle (not obese, non-smokers, physically active, eating a healthy diet).  Thus, it indicates that the effect of moderate drinking on lowering the risk of diabetes cannot be explained by other healthy lifestyle habits of such drinkers.  Moderate drinking should be considered as a complement, and not as an alternative, to other healthy lifestyle habits that lower the risk of chronic diseases such as diabetes and coronary heart disease.

For the full critique of this paper by members of the International Scientific Forum on Alcohol Research, please click here.